IJCRR - 13(16), August, 2021
Date of Publication: 30-Aug-2021
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Electrocardiographic and Echocardiographic Evaluation of Subjects with Atrial Fibrillation
Author: Gharge Sushilkumar Sunil, Vivek E. Redkar
Abstract:Introduction: Atrial fibrillation (AF) is one of the most commonly sustained arrhythmia and an important cause of morbidity, mortality, and health care expenditure. it is associated with many predisposing factors like an underlying cardiovascular disease. The most notable is rheumatic mitral stenosis. Hypertension (HTN) and coronary artery disease (CAD) are the most common risk factors in the developed world. Aim: Here is to evaluate the electrocardiographic and echocardiographic findings in patients with atrial fibrillation patients. Method: We have adopted for our research is a cross-sectional, observational, non-interventional, study. This study the period of October 2018 to March 2020. Result: The male: female ratio was 1: 0.80IHD (40.76%) was the most common antecedent cause for AF, followed by Rheumatic heart disease(RHD), Mitral stenosis(MS) (both 33.84%) and hypertension(HTN) (31.53%). Conclusion: Electrocardiographic evaluation of the subjects revealed ischemic heart disease as the most common finding. Followed by echocardiographic evaluation showed left atrial enlargement and mitral stenosis..
Keywords: Atrial fibrillation, Hypertension, Coronary artery disease, Diabetes mellitus
Atrial fibrillation (AF) is one of the most commonly sustained arrhythmias and an important cause of morbidity, mortality, and health care expenditure.1, 2 Currently there are 2.3 million people in the US who have AF and this is expected to rise to 5.6 million by 2050. In persons aged 60-65, the prevalence is around 1%, but in those > 80 years of age, the prevalence is 8-10%. It is present in 6 - 10% of patients older than 70 years.2 The prevalence is also higher in men than women and in whites than black ethnicity.2 It is also associated with a 5-fold risk for stroke and 2 fold risk for all-cause mortality.3, 4 It is described as an irregular and often rapid heart rhythm. The symptoms of AF may vary from person to person. In many people, AF may cause symptoms but doesn‘t do any harm and many have no symptoms at all. Palpitations are the most common symptom with intermittent AF, anxiety and irregular fluttering are others.5 In patients with an uncontrolled ventricular response exercise intolerance and Dyspnoea may also develop which is mostly related to congestive heart failure (CHF). Thromboembolism is the most threatening complication of AF.
AF can be present in a structurally normal heart (lone AF) but usually, it is associated with many predisposing factors like an underlying cardiovascular disease. The most notable is rheumatic mitral stenosis. Hypertension (HTN) and coronary artery disease (CAD) are the most common risk factors in the developed world. Other risk factors are - Diabetes Mellitus (DM), congestive heart failure (CHF), valvular Heart diseases (VHD), and previous myocardial infarction (MI). Clinical hyperthyroidism is also associated with new-onset AF but, prevalence is low. In developing countries, Rheumatic VHD, HTN, and congenital heart disease (CHD) are important causes.6
Rheumatic heart disease:
One of the most common complications is AF. Historically rheumatic MS has been proven to be closely related to AF.7 The incidence of AF in RHD is about 40%. Devil et al reported the incidence of AF to be clearly related to age. AF was uncommon in young patients, but increased in frequency each decade and occurred in the majority of patients after the 4thdecade.8
William Kennel et al reported an incidence rate of 10.2% and 26.5% among men and women respectively for RHD among their AF patients.2 Adell Cullen et al, reported 19% incidence of RHD among their AF patients.9 Aberg et al, reported RHD among 11% of patients with AF.10 Eugene Rich et al observed RHD in 10% of patients with AF.11 The prevalence of RHD in India is high. In a study conducted by T.K.Raman et al, RHD was observed in 58% of the cases of AF studied by them.12
Hypertensive heart disease:
It is designated if a subject is hypertensive and had either LVH by ECG, cardiac enlargement by X-ray, increased LV mass index (>131 g/m in men and >110 g/m2 in women) or a cardiac failure.13The incidence of AF in HTN varies and the frequency of fibrillation is directly related to the chronicity, severity and associated complications of HTN. Studies on the precursors of AF have reported hypertensive heart disease to be the one most commonly associated with AF. William Kennel et al, reported that hypertensive HD accounted for 45.7% in men and 51.2% among women of the cases of AF.2 De Carvalho Filho et al, observed 51% of hypertensive HD among their patients with AF.14Adell Cullel et al reported hypertensive HD in 34% of the series 1 of AF patients studied by them.10 Leclercq et al. in their study on PAF had HTN as the only disorder in most of their cases.15
To evaluate the electrocardiographic and echocardiographic findings in patients with atrial fibrillation patients admitted in Krishna hospital and Medical Research Centre, Karad.
1. To assess the frequency of underlying heart disease in patients with atrial fibrillation.
2. To study various clinical presentations of atrial fibrillation.
3. To evaluate the electrocardiographic and echocardiographic findings in patients with atrial fibrillation.
Type of study:
This was a cross-sectional, observational, non-interventional, study. The study was conducted in the Department of General Medicine of Krishna Institute of Medical Sciences and Research Center, Karad, in patients of inpatient department of tertiary care, teaching institute during the period of October 2018 to March 2020.
According to, ?Clinical and etiological study of atrial fibrillation in upper Assam?, Kotokey RK et al, the prevalence of RHD in patients of AF was 43.5 %.16
Hence, we chose p=43.5 %, q= 1-p i.e. 56.5 %. Using the formula for cross-sectional studies, with a relative precision of 20% at 95% confidence interval (e=20% of 43.5), and p=43.5%, the minimum sample size comes up to 127 patients which was rounded off to 130 patients.
1. Hemoglobin by fully automated 3 part cell analyzer
2. Total leukocyte count by fully automated 3 part cell analyzer
3. Platelet count by fully automated 3 part cell analyzer All CBC parameters were performed in an automated 3 part analyzer by Nihon Kohden (Model number MEK 6420P)
4. Prothrombin time (PT/INR) by Stag analyzer (Model number- BT3305B301)
1. Blood urea by Urease-GLDH (Glutamate dehydrogenase) method
2. Serum Creatinine by Modified Japanese Female Facial Expression (JAFFE’S) method
3. Serum Sodium by ISE (ion-selective electrode) based method
4. Serum Potassium by ISE (ion-selective electrode) based method
5. Random blood sugar by Hexokinase-mediated reaction
6. Serum Calcium by Arsenazo method
7. Serum Magnesium by Xylidyl blue method
8. Serum Phosphorus by UV Molybdate method
9. Liver function tests by Calorimetric
10. Serum T3, T4, TSH by immune-unsymmetric assay (automated) on TOSOH
All biochemistry parameters analyzed in EM 360 analyzer by Transasia
The mean age of patients in our study was 64.42 ± 14.66 years (Range 21-95 years). The majority of the patients were seen in the age group of 61-80 years (75 patients, 57.7%), followed by 41-60 years (30 patients, 23.1%), >81 years (13 patients, 10%) and 20-40 years (12 patients, 9.2%). The majority of the participants were males (55.4%) and rest were females (44.6%). The male: female ratio was 1: 0.80 Ischemic heart disease (IHD) (40.76%) was the most common antecedent cause for AF, followed by RHD, MS (both 33.84%) and HTN (31.53%).Other causes are MR (6.92%), Hyperthyroidism (3.84%) , ASD, PHT, TR (all 1.5%) , AS, AR and COPD (0.8%).There was no significant difference in the distribution of etiology among both sexes.( chi sq. value = 33.575 , p-value = 0.117) Dyspnoea (97.7%) was the most common presenting symptom , followed by pedal edema ( 64.6%) , palpitations (61.5%), chest pain (60.8%) , cough (13.1%) , hepatomegaly (3.8%) , hemoptysis (2.3%) , abdominal pain (1.5%) and syncopal attacks (0.8%).All patients had an irregularly irregular pulse. The average pulse rate was 119.34± 17.54 bpm. The range was 66-168 bpm. The pulse rate was >110 bpm (67.7%) in the majority of the patients followed by 90-110 bpm ( 26.2%) and <90 bpm (6.2%). The average pulse deficit was 12.08 ± 2.33. The range was 6-16. The pulse deficit was > 10 in 87 patients i.e. 66.9% and ≤ 10 in 43 patients (33.1%).
The mean Spontaneous bacterial peritonitis (SBP) was 142.38 ± 17.38 mmHg (Range 90-170). The mean Diastolic blood pressure (DBP) was 86.46± 10.11mmHg (Range 60-110). The mean random blood sugar (RBS) was 149.83 ± 51.09 mg/dl (Range 74-364). The mean Urea was 37.00 ±18.84 mg/dl (Range 14- 142). The mean Creatinine level was 1.26 ± 0.57 mg/dl (Range 0.6-4.5). The mean Sodium levels were 139.08 ± 5.55 mEq/l (Range 123.0-149.0). The mean Potassium levels were 4.09 ± 0.45 mEq/l (Range 3-5). Jugular venous pulse (JVP) was raised in 80 (61.5%) patients. Chest X-ray was normal in 71 (54.6%) patients. Cardiomegaly was seen in 58 (44.6%) patients. One patient (0.8%) had features of Chronic obstructive pulmonary disease (COPD). ECG was done using a 12-lead electrocardiogram. The rate varied from 74- 180 bpm and in the majority of the patients i.e 45%, the rate was 90-110bpm. The rhythm was irregularly irregular in all patients. P -waves were absent in all patients. QRS complexes were normal, but irregular in time and varied in amplitude.
AF is one of the most commonly sustained arrhythmia and an important cause of morbidity, mortality, and health care expenditure.1,2AF is identified and treated early, risk of serious or life-threatening problems are minimal. This study was conducted on 130 patients of AF to assess the presenting symptoms, underlying predisposing factors, electrocardiographic and echocardiographic findings in patients with AF.
In our study, the mean age of patients in our study was 64.42 ± 14.66 years (Range 21-95 years). The majority of the patients were seen in the age group of 61-80 years (75 patients, 57.7%), followed by 41-60 years (30 patients,23.1%), >81 years (13 patients, 10%) and 20-40 years (12 patients, 9.2%). These results are similar to previous Indian studies. In a study by Vivek GC et al, the mean age of the patients was 54.84 ± 17.49 years (Range 30-80) and majority belonged to 60-79 age group i.e. 30%.45 In another study by Sharma et al, and Gurpal Singh et al47 the mean age was 40.0 ± 7.0 years and 57.33 years respectively. Kulkarni et al reported the mean age for AF as 59.6years.18,19,20 The Framingham heart study provides the single best evidence for chronic AF and proves that the incidence rises with increasing age.13The prevalence of AF was 0.5% in 50-59 years and rises to 8.8% in 80-89 years.49 A study by Prakash SK and Chugh SK reported that all cases of AF due to CAD were above 50 years.22
Few studies in western countries, where the major cardiac precursors of AF are HTN and CAD also found a higher incidence of AF in increasing age groups.23,29,24 In the Indian population, the major cardiac precursors of AF is RHD.
The symptoms of AF may vary from person to person. In many people, AF may cause symptoms but doesn‘t do any harm and many have no symptoms at all. Palpitations are the most common symptom with intermittent AF, anxiety and irregular fluttering are others.5 In our study , Dyspnoea (97.7%) was the most common presenting symptom , followed by pedal edema ( 64.6%) , palpitations (61.5%), chest pain (60.8%), cough (13.1%), hepatomegaly(3.8%), hemoptysis (2.3%), abdominal pain (1.5%) and syncopal attacks (0.8%).Similarly, Vivek GC et al, reported that, 82% cases had dyspnoea followed by palpitations(78%), edema (66%), chest pain(36%), abdominal pain (18%), hemoptysis(10%) and syncopal attacks (4%).17 Similar symptoms were observed by Gurpal Singh et al47 too.19 Table 1 given below indicates the comparison baseline characteristics in AF patients.
AF can be present in a structurally normal heart (lone AF) but usually, it is associated with many predisposing factors like an underlying cardiovascular disease. In India, the incidence of RHD is around 35-45% of all cardiac cases.25 It is the most common antecedent disease for atrial fibrillation. In our study, IHD (40.76%) was the most common antecedent cause for AF, followed by RHD, MS (both 33.84%) and HTN (31.53%). Other causes are MR (6.92%), Hyperthyroidism (3.84%), ASD, PHT, TR (all 1.5%), AS, AR and COPD (0.8%). There was no significant difference in the distribution of etiology among both genders. Vivek GC et al, reported that RHD (50%) was the most common cause for AF, followed by IHD and HTN (12%) cases, only HTN (12%), IHD alone(8%), ASD (4%), cardiomyopathy (6%)cases, COPD (6%), and Thyrotoxicosis (2%).17 Gurpal Singh et al47 reported the etiology of AF to be RHD (26%) , DCM (23%), HTN (14.06%) , MVP, thyrotoxicosis (9.37% each),IHD (3.1%), ASD (1.5%), digitalis toxicity(1.5%) and lone fibrillation (1.5%).Similar results were reported by Prakash SK and Chugh SK et al, reported that 91.61% of AF was secondary to chronic RHD, 5.94% due to CAD.22 The Framingham heart study reported that, RHD and cardiac failure were most predictive precursor of AF. 24Davidson et al, in their study of 704 cases of AF, reported atherosclerotic CVD (55%) including MI, hypertensive heart disease and CAD as the most frequent cause associated with AF. Chronic RHD (22.8%), COPD (2.8%), WPW syndrome (2.6%) and thyrotoxicosis (2.6%),cardiomyopathy (0.9%),MVP (0.9%), sick sinus syndrome (0.7%),myocarditis (0.6%), pulmonary embolism (0.3%) and ASD (0.3%)were among others. 55 In two studies by Levy S et al, it was reported that RHD is present about 20-23% of AF patients and ASD is the most common congenital heart disease reported to cause AF.They also reported a case of thyrotoxicosis.26,27 The Framingham heart study reported hypertensive heart disease as the most common cardiac precursor for AF.13
CCF was the most common complication seen in 90 patients (69.3%). Of these, 3.07%patients died and one patient had associated DCM. No complications were seen in 30.8%. Similarly, Vivek GC et al. reported that 80% cases developed CCF.17 The ALFA study by Levy et al, showed 38% of patients had CCF and a study by Sharma et al, reported CCF was present in 30%.26,18 Other complications like stroke,cor-pulmonale and superior mesenteric ischemia were also reported in few other studies.13,17,28
Atrial fibrillation is the most common form of arrhythmia encountered during the regular clinical practice. In consideration to the present study, dyspnoea and palpitations were the commonly observed presenting complains in patients. There was no specific gender predominance found in the patient distribution. Ischemic heart disease and rheumatic heart disease were the leading etiological factors. The electrocardiographic evaluation of the subjects revealed the ischemic heart disease as the most common finding. Followed by echocardiographic evaluation showed left atrial enlargement and mitral stenosis.
Conflict of Interest: There is no conflict of Interest
Source of Funding: No Source of Funding
Authors Contribution: This is a collaborative work among all authors. Dr. Gharge Sushil Kumar Sunil, Dr. Vivek E. Redkar performed the statistical analysis, wrote the protocol, and wrote the first draft of the manuscript. Dr. Gharge Sushilkumar Sunil, Dr. Vivek E. Redkar managed the literature searches. All authors read and approved the final manuscript.
1. Floria M, Tanase MD. Multimodality Echocardiographic Assessment of Patients Undergoing Atrial Fibrillation Ablation. Echocard Heart Fail Card Electrophy. 2016; 10(3):19:65.
2. Kannel WB, Benjamin EJ. Current perceptions of the epidemiology of atrial fibrillation. Card Clin. 2009 Feb 1;27(1):13-24.
3. Hart RG, Benavente O, McBride R, Pearce LA. Antithrombotic therapy to prevent stroke in patients with atrial fibrillation: a meta-analysis. Ann. Intern. Med. 1999 Oct 5;131(7):492-501.
4. Benjamin EJ, Wolf PA, D‘Agostino RB, Silbershatz H, Kannel WB, Levy D. Impact of atrial fibrillation on the risk of death: the Framingham Heart Study. Circulation. 1998 Sep 8;98(10):946-952.
5. Armstrong WF, Ryan T. Feigenbaum‘s Echocardiography. 8th ed. Philadelphia: Wolters Kluwer -- Medknow Publications; 2019.
6. Makwana A, Shrivastava S, Trivedi AH. Clinical Profile of Atrial Fibrillation. Ind J Appl Res. 2015;5(October):537–540.
7. Lip GY, Beevers DG. ABC of atrial fibrillation: history, epidemiology, and importance of atrial fibrillation. Bri Med J. 1995 Nov 18;311(7016):1361.
8. Cullell TA, Samaniego FS, Beistegui CC, Pijuan NM, Olona JF, García EJ. Total Arrhythmia Due to Atrial Fibrillation. Primary Care Approach. Atencion primaria. 1993 Apr 30;11(7):333-336.
9. Aberg H. Atrial fibrillation: I. A study of atrial thrombosis and systemic embolism in a necropsy material. Acta Medica Scandinavica. 1969 Jan 12;185(1?6):373-379.
10. Rich EC, Siebold C, Campion B. Alcohol-related acute atrial fibrillation: A case-control study and review of 40 patients. Archives of Internal Medicine. 1985 May 1;145(5):830-833.
11. Raman T. Auricular Fibrillation. Ind Hear J. 1951;39:289–91.
12. Braunwald E. Heart disease. A Textb. Cardiovasc. Med. 4th ed., 1992, p. 1245; 1683–1684.
13. Koskinen PE, Kupari MA, Leinonen HA, Luomanmäki K. Alcohol and new onset atrial fibrillation: a case-control study of a current series. Heart. 1987 May 1;57(5):468-73.
14. Leclercq JF, Attuel P. Paroxysmal atrial fibrillation. J Cardiogr Suppl. 1993.43(12).1515- 21
15. Ohkawa S, Inoue J, Sugiura M. A clinicopathologic study of dilated cardiomyopathy in the aged. J Cardiogr Suppl. 1986.9.35-47
16. Chandrashekar V, Gadwalkar, SrikantRBasavareddy A, Basavareddy R. A clinical, electrocardiography and echocardiography study of atrial fibrillation in a tertiary care teaching hospital. J Transl Intern Med. 2014;2(4):168.
17. Sharma S, Joshi S, Gupta A. Prospective study of atrial fibrillation in a large industrial hospital: Therapeutic implications. Ind Heart J. 2002;23:109–13.
18. Gurpal S, Nayar S. Study of left atrial size in atrial fibrillation. Ind Heart J. 2002;36:276–81.
19. Kulkarni A, Mulay D, Jilla P. A study of the relation between left atrial size and atrial fibrillation. J Assoc Phys Ind. 2002;50:1555.
20. Zimmerman MC, Lazartigues E, Sharma RV, Davisson RL. Hypertension caused by angiotensin II infusion involves increased superoxide production in the central nervous system. Circul Res. 2004 Jul 23;95(2):210-6.
21. Prakash S, Chugh S. Atrial fibrillation in women. J App Phy. 1973;(21):953– 5.
22. Kitchin AH, Milne JS. Longitudinal survey of ischaemic heart disease in a randomly selected sample of the older population. Heart. 1977 Aug 1;39(8):889-93.
23. Rose GP, Baxter PJ, Reid DD, McCartney P. Prevalence and prognosis of electrocardiographic findings in middle-aged men. Heart. 1978 Jun 1;40(6):636-43.
24. Manyari DE, Patterson C, Johnson D, Melendez L, Kostuk WJ, Cape RD. Atrial and ventricular arrhythmias in asymptomatic active elderly subjects: correlation with left atrial size and left ventricular mass. Amer Hear J. 1990 May 1;119(5):1069-1076.
25. Singh B. Nonvalvular atrial fibrillation in India—time to pause, think, and change. Ind Heart J. 2018 Nov;70(6):767.
26. Levy S. Atrial fibrillation, the arrhythmia of the elderly, causes and associated conditions. Anadolu Kardiyol Derg. 2002 Mar;2(1):55-60
27. Wolf PA, Abbott RD, Kannel WB. Atrial Fibrillation: A Major Contributor to Stroke in the Elderly: The Framingham Study. Arch Intern Med. 1987;147(9):1561–1564
28. Henry WL, Morganroth J, Pearlman AS, Clark CE, Redwood DR, Itscoitz SB, Epstein SE. Relation between echocardiographically determined left atrial size and atrial fibrillation. Circ. 1976 Feb;53(2):273-9
29. Campbell A, Caird FI, Jackson TF. Prevalence of abnormalities of the electrocardiogram in old people. Bri Heart J. 1974 Oct;36(10):1005.